Rising to the Fall Challenge

It’s generally agreed that reducing hospitalizations and minimizing hospital length of stay is in the best interest of elderly patients, as it prevents infections, deconditioning, and episodes of delirium.

On the other hand, less time in the hospital means the elderly patient is no longer under the health system’s watchful eye. This problem can be partially solved by empowering patients to collect their own vital signs and other biometric data. But what if the flow of data stops? Is it a temporary disruption, or an actual emergency? How can a patient who falls, or is otherwise incapacitated, reach out for help?

As the population ages, and as pressure mounts to keep patients out of the hospital, these questions grow in urgency. Falls have been called “the great plague of the modern era,” already affecting one in four elderly U.S. patients each year, leading to millions of ED visits and almost a million hospitalizations. Falls have become the leading cause of accidental death among the elderly, with the CDC reporting an increasing death rate over the past decade. Survivors are often left with debilitating injuries, including fractures and concussions.

Remote monitoring of falls and other emergencies dates back to the 1970s, when gerontologist Dr. Andrew Dibner and his sociologist wife, Dr. Susan Dibner, patented a wireless alarm system that could be activated by a portable push button. Their first personal emergency response system (PERS) was a simple auto-dialer that sent a pre-recorded message to the service in the event of a button press, or if too much time elapsed without routine telephone usage. After promising early controlled trials showed cost savings and reduced time spent in nursing homes, the company, Lifeline Systems, Inc., expanded operations and developed a central call center. By 1983 Lifeline had over 20,000 subscribers wearing an emergency pushbutton neck pendant or wristband.

An industry sprang up, with companies like LifeCall running a campy, dramatized commercial beginning in the late 1980s featuring an elderly woman who exclaimed, “I’ve fallen, and I can’t get up!” The service could also be set to notify primary care doctors or designated family members.

Even as the popularity of PERS exploded, new methods of fall detection emerged, such as wearable accelerometers and impact detectors, specialized motion detectors, cameras and microphone setups, and floor pressure sensors. Few peer-reviewed studies exist comparing the real-world effectiveness of various systems, but there’s definitely a trade-off: a passive monitoring system that can automatically activate emergency response, even if the patient is unconscious, can certainly catch more events than a user-activated system, but is also prone to more false alarms. And patients tend to view automated monitors with suspicion and distrust.

As passive monitoring technology is refined, however, its appeal should grow – at least among insurers and managed care organizations. A major benefit to the systems consisting of cameras, microphones and distributed sensors is the abundance of collected data. Properly analyzed, this data can aid efforts at risk stratification and ultimately, fall prediction. For example, the use of GE QuietCare’s passive monitoring system at an assisted living facility was able to give health professionals insight into patient’s sleep behavior, and performance of activities of daily living. This permitted the administration to make more informed selections of supervision and care level. A peer-reviewed study of QuietCare showed the system’s insights into appropriate placement led to patients experiencing fewer falls, fewer hospitalizations, and fewer transfers to nursing homes.

We might expect some peace of mind after equipping our elderly parents’ homes to detect emergencies. But that could quickly turn to a sense of betrayal if the network of sensors and cameras analyzes their gait and sleep, only to conclude they’re better off living in another setting. To me, it seems that these systems can improve patient outcomes, but we might not accept the recommendations if they tell us something we don’t want to hear. The button-activated speakerphone system from decades ago is outdated technology, but at least it was entirely under the control of the patients. We may look back on personal emergency response systems as a state we’ve fallen from…and can’t get back up to.

Editor At Large
A specialist in emergency medicine informatics at Mount Sinai in Manhattan, Dr. Genes is EPM's resident tech guru. He practices emergency medicine at Mount Sinai Hospital but can be found sharing his wit and wisdom all over the web.